Single Use Non-Stormwater Discharge Form
** * ( THIS FORM MUST BE FILED UP EVERY TIME WHEN DISCHARGING NON STORM WATER)
DATE
Name of Company / Organization:
Address:
City :
Zip Code:
Address
of Discharge, if different from above:
Phone :
Type of Organization:
Individual
Business
Industrial
Govt. Agency
Other
Type of Discharge:
Landscape irrigation
Rising ground water
Foundation drains
Flows from riparian habitats
Uncontaminated Street wash water
Discharges from potable water sources
Uncontaminated pumped ground water
Fire fighting water runoff
Diverted stream flow
Ground water infiltration
Flows from wetlands
Water line flushing
Non commercial car washing
Flows from emergency
Utility vault vacating
IF Other Explain:
Date of discharge:
Volume of discharge:
Time of Discharge:
Name of Applicant:
Email Address: